Legacy At Salina

The facility had a census of 41 residents. Based on record review and interview, the facility failed to submit complete and accurate staffing information through the Payroll Based Journal (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2024 Quarter 4 indicated the facility had excessively low weekend staff.On 09/09/24 at 03:30 PM, Administrative Staff A verified the facility would complete the quarterly PBJ data and then would send that information to corporate, then corporate would send that collected information to Prime View, which is a data collection program, and that was the final information that was submitted to the PBJ data. Administrative Staff A verified the facility had adequate staffing during the 2024 Quarter 4 and stated they were unsure how it was incorrectly submitted. The Reporting Direct Care Staffing Information (PBJ) policy, dated August 2022, documented that direct…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 40 residents. The sample included 3 residents. Based on observation, record review, and interview, the facility failed to ensure staff immediately reported an allegation of potential abuse and neglect to the administrator. Resident (R)1 reported an allegation of potential abuse and neglect to Licensed Nurse G, after Certified Nurse Aide M did not provide assistance to R1 for urinary care and R1 had a soaked brief. LN G did not report the incident to administrative staff. This failure placed R1 at risk for continued neglect. Findings Included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), and urine retention (lack of ability to urinate and empty the bladder). R1's Quarterly Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 41 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the 41 residents who received their meals from the facility's kitchens. This placed the residents at risk for foodborne illness. Findings included: - On 01/02/24 at 08:10 AM, observation in the kitchen revealed: One unsealed unlabeled plastic bag of tater tot patties, one unsealed unlabeled plastic bag of tater tots, and one bag of unsealed, unlabeled plastic bag of chicken strips in the white upright freezer. The outside of the refrigerator freezer had numerous different-sized areas of blackish substance. Inside the refrigerator were numerous different-sized specks of food particles on the door shelves, below the bottom drawers, and the top and middle compartments of the door. The walk-in refrigerator had an open box with an uncovered bunch of celery which had a white substance on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 41 residents. The sample included 14 residents. Based on observation, record review, and interview the facility failed to provide a safe, clean comfortable, and homelike environment in the dining room. This placed the residents at risk of an unsafe and uncomfortable environment. Findings included: - On 01/02/24 at 11:35 AM, observation in the dining room revealed the floor throughout the dining room had blackish gray build up and the floor tile located next to the heater had an approximately four-inch wide by a nine-inch long missing piece of tile. On 01/04/24 at 10:40 AM, Maintenance Staff (MS) U verified the above findings and stated he had not waxed the dining room floor because the facility was going to replace it, but he did not know when. On 01/04/24 at 10:58 AM, Administrative Staff A verified the dining room floor had not been waxed for a while and stated the facility was going to purchase new flooring, so staff had not waxed the old one. Administrative Staff A said the facility received one estimate but felt like it was high; the facility then…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 41 residents. The sample included 14 residents. Based on observation, interview, and record review, the facility failed to provide a safe environment free of chemical hazards for five cognitively impaired independently mobile residents and failed to ensure a safe environment for Resident (R) 33. The deficient practice placed the affected residents at risk for preventable accidents, falls, and related injuries. Findings included: - On 01/03/24 At 08:07 AM observation revealed a bottle of Windex Multi-Surface Cleaner and Lime Away bottles sitting on an open shelf below the fish aquarium. The Lime Away bottle was labeled to keep out of reach of children. On 01/03/24 at 08:09 AM, Administrative Nurse D, stated one of the residents cleaned the aquarium and placed the cleaning agents under the aquarium, and left them there. Administrative Nurse D verified the cleaning agents should not have been left under the aquarium and took them to have them locked up. The facility's Storage Areas,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 41 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to store drugs and biologicals for two medication storage carts placing the residents at risk for missing medications and unsafe access to medications. Findings included: - On 01/02/24 at 10:39 AM, observation revealed a treatment/medication cart in the living room area was unattended and unlocked. The unlocked drawers contained insulin (a hormone that lowers the level of glucose in the blood) for four different residents. Licensed Nurse H verified the cart should be locked when unattended. On 01/03/24 at 12:09 PM, observation revealed a medication cart in the living room area unattended and unlocked. Certified Medication Aide (CMA) R verified the medication cart should be locked when unattended. On 01/04/24 at 01:00 PM, observation revealed Resident (R) 5 in a wheelchair in the dining room attempting to open drawers on the medication cart. On 01/08/24 at 10:58 AM, Administrative Nurse D stated the medication carts should be locked if…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 41 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to provide proper infection control practices related to point of care testing for COVID-19 (a highly contagious respiratory virus) and also failed to sanitize a resident's walker after it was used by another resident who had not been feeling well. This placed the residents at risk for infectious disease. Findings included: - On 01/03/24 at 07:45 AM, observation revealed Resident (R)25 stated she did not feel well and refused her medication. At 10:07 AM, observation revealed Certified Nurse Aide (CNA) N placed R33's silver walker in front of R25 and told her to hold onto the walker to stand up. CNA N had R25 pivot turn and sit down in her wheelchair. At 02:30 PM, observation revealed R33 sat in her wheelchair with a gait belt around her waist in the bathroom. With Certified Nurse Aide (CNA) M on her right side and CNA P on her left, staff assisted her to stand. CNA M pulled down R33's pants and incontinence brief and assisted her to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 41 residents. The sample included 14 residents. Based on observation, record review, and interview the facility failed to provide adequate lighting in the main dining room. This put the residents at risk of not being able to see and enjoy their meals. Findings included: - On 01/02/24 at 11:35 AM, observation in the dining room revealed: A ceiling fan light fixture had three burnt-out light bulbs. A fluorescent ceiling light, approximately three feet by 18 inches had burnt-out light bulbs. On 01/04/24 at 10:40 AM, Maintenance Staff (MS) U verified the above light issues and stated he had not had time to replace the bulbs. The facility's Maintenance Service Policy, revised in December 2009, documented that maintenance service would be provided to all areas of the building, grounds, and equipment. The maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner. The facility failed to provide adequate lighting in the main dining room for the residents who ate their meals there. This placed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 41 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 30 had a physician's order and was assessed for the ability to safely self-administer medications left at the bedside. This placed R30 at risk for improper use of medication and related side effects. Findings included: - R30's Electronic Medical Record (EMR) documented R30 had diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, a history of transient ischemic attack (TIA- temporary episode of inadequate blood supply to the brain), and major depressive disorder (major mood disorder which causes persistent feelings of sadness). R30's Quarterly Minimum Data Set (MDS), dated [DATE], documented R30 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R30 independent with activities of daily living (ADLs). R30's Care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 41 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to honor Resident (R) 4's preference to receive three showers per week. This placed R4 at risk for decreased self-determination and impaired psychosocial well-being. Findings included: - The Electronic Medical Record (EMR) for R4 documented diagnoses of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods). The Annual Minimum Data Set (MDS), dated [DATE], documented R4 had intact cognition and required substantial to maximum assistance with showering, toileting, supervision with personal hygiene, and dressing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 41 residents. The sample included 14 residents, with three reviewed for Medicare Liability Notices. Based on record review and interview, the facility failed to provide the resident (or their representative) a fully completed Advanced Beneficiary Notice (ABN) for skilled services for Resident (R) 17, R31, and R36 which included the estimated cost of services. This placed the resident at risk for uninformed care decisions. Findings included: -The Medicare Advanced Beneficiary Notice (ABN) informed the beneficiary that Medicare may not pay for future skilled therapy services and provided a cost estimate of continued services. The form included an option for the beneficiary to (1) receive specified therapy listed, and bill Medicare for an official decision on payment. I understand if Medicare does not pay, I am responsible for payment, but can appeal to Medicare. (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for services. (3) I do not want the listed therapy services. The facility lacked documentation R17 was provided…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 41 residents. The sample included 14 residents, with six reviewed for bathing. Based on observation, record review, and interview, the facility failed to provide consistent bathing services as care planned for one sampled resident, Resident (R) 4. This placed the resident at risk for poor hygiene. Findings included: - The Electronic Medical Record (EMR) for R4 documented diagnoses of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods). The Annual Minimum Data Set (MDS), dated [DATE], documented R4 had intact cognition and required substantial to maximum assistance with showering, toileting, supervision with personal hygiene,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 41 residents. The sample included 14 residents, with two reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to provide adequate respiratory care and services for Residents (R) 38, and R31 when staff failed to store their oxygen tubing and cannula in a sanitary manner when not in use. This placed the residents at risk for an infection. Findings included: - The Electronic Medical Record (EMR) documented R38 had diagnoses of heart failure, hemiplegia of the non-dominant side (paralysis of one side of the body), and dependence on supplemental oxygen. R38's admission 5-day Medicare Minimum Data Set (MDS), dated [DATE], documented R38 had intact cognition and required partial assistance for ambulation, was dependent upon staff for transfers, partial to moderate assistance with personal hygiene, upper functional impairment on one side, and lower functional impairment both sides. The assessment further documented R38 required oxygen use.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 41 residents. The sample included 14 residents with two reviewed for behaviors. Based on observation, record review, and interview, the facility failed to complete a trauma-informed care assessment for one sampled resident, Resident (R) 1, who had behaviors and past traumatic events in her life. This placed the resident at risk for unmet behavioral health needs. Findings included: - The Electronic Medical Record (EMR) for R1 documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), personality disorder (a consistently dysfunctional pattern of thinking and behavior that reflects suspicion or lack of interest in others), panic disorder (frequent and unexpected panic attacks), and schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 41 residents. Based on observation, record review, and interview the facility kitchen staff failed to provide food prepared by methods that conserve nutritive value, flavor, and appearance when dietary staff failed to follow a recipe while preparing one resident's pureed diet. This placed the resident at risk for impaired nutrition. Findings included: - On 01/03/24 at 11:30 AM Dietary Staff (DS) DD, with Dietary Manager (DM) BB overlooking, stated the facility had one resident who received a pureed diet. DS BB washed hands, applied gloves, placed one four-ounce piece of twice-baked chicken into a blender container then added two ounces (oz) of brown gravy, and blended. DS DD reported it was not the right consistency, added one-half oz brown gravy, and blended to the consistency of pudding. DS DD poured it into a custard bowl and placed it on the counter. DS DD used a new blender container, placed four ounces of country vegetables into the blender container, and added two oz. of liquid from the vegetables, blended to the consistency of pudding, poured…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility identified a census of 37 residents with one kitchen and one dining room. Based on observation, record review, and interviews, the facility failed to ensure sanitary food storage. This deficient practice placed the residents at risk for food-borne illness. Findings Include: - On 05/23/22 at 07:08AM an initial walk-through of the kitchen's food storage area was completed. The walkthrough revealed that the floors in the storage areas were sticky in front of the dry food storage area. Upon inspection of the kitchen's walk-in freezer unit, open but undated bags of fries, chicken strips, potato tots, hash browns, peas, and chicken bites were observed. The freezer unit blower vent had visible dust and lint buildup covering the vents blowing towards the food stored in the unit. Inspection of the kitchen's walk-in refrigerator unit revealed an open but undated bag of tortillas. The refrigerator unit blower vent had visible dust and lint buildup covering the vents blowing towards the food stored in the unit. Inspection of the dry good storage rack outside the walk-in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 37 residents. The sample included 13 residents. Based on observation, record review, and interviews, the facility failed to develop an individualized person-centered care plan related to bladder incontinence for Resident (R) 10, R16, and R30 and failed in the development of person-centered care plan related to monitoring of antihypertensive medication for R31. This deficient practice placed the residents at risk of not achieving and/or maintaining their highest practicable physical, mental, and psychosocial well-being. Findings included: - R10's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hypertension (elevated blood pressure), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), overactive bladder (a frequent and sudden urge to urinate that may be difficult to control), and stress incontinence (is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 37 residents. The sample included 13 residents. Based on record review and interview the facility failed to provide scheduled weekend activities. This placed the residents at risk for boredom and impaired psychosocial well-being. Findings included: - On 05/25/22 at 10:30 AM, during resident council meeting, the four present resident council members voiced a concern regarding the lack of scheduled resident activities on the weekends. Review of the February, March, April and May 2022 Activity Calendars revealed no scheduled resident activities for the weekends. The calendars documented family and friend visits as resident activities. On 05/25/22 at 1:12 PM, Activity Z verified the facility had no scheduled activities on the weekends for the residents and stated she would set up dominos and scrabble in the living area for resident who wanted to play them. Activity Z stated she was employed with the facility since February 2022;she was working on getting more scheduled activities on the weekend. On 05/31/22 at 10:30 AM, Administrative Nurse E stated she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 37 residents. The sample included 13 residents, with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the failure to monitor antihypertensive medication (class of medication used to treat hypertension [high blood pressure]), failure to follow physician ordered parameters for monitoring of antihypertensive medication, the lack of behavior monitoring on psychotropic (medications which alter mood or thoughts) medications and the lack of a stop date for an as needed antidepressant. These deficient practices placed Resident(R) 10, R31, R16, R33 and R14 at increased risk for side effects of unnecessary medications or complications. Findings included: - R10's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hypertension (elevated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 37 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections when staff failed to wear a mask inside the facility, left uncovered clean laundry in a cart in the hall, and hung Resident (R) 187's personal clothing on the hand rail outside her room. The facility further failed to ensure visitors to isolation room wore proper personal protective equipment (PPE). The facility further failed to ensure staff followed infection control principles during COVID (highly contagious, potentially fatal respiratory infection) test. This placed the 37 residents at risk for infection. Findings included: - On 05/23/22 at 07:07 AM an unidentified facility staff member who was not wearing a mask answered the facility door and allowed the survey team to enter. A sign posted at the entrance directed a mask must be worn at all times in the facilty. On 05/24/22 at 03:56 PM, observation revealed as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 37 residents. The sample included 13 residents with one resident reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure R10's right to be treated with respect, dignity, related to bladder incontinence when the facility staff referred to residents as heavy wetters and placed cloth incontinent pads in R10's wheelchair. This deficient practice placed the residents at risk for negative psychosocial outcomes and decreased autonomy and dignity. Findings included: - R10's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hypertension (elevated blood pressure), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), overactive bladder (a frequent and sudden urge to urinate that may be difficult to control), and stress incontinence (is the unintentional loss of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 37 residents. The sample included 13 residents. Based on record review and interview, the facility failed to develop a discharge summary for one of the residents reviewed for discharge that included a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay and post discharge pan for Resident (R) 38. This placed the resident at risk for receiving inadequate care. Findings included: - R38's Electronic Medical Record (EMR) revealed the resident admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), dated 03/09/22, documented the resident had a Brief Interview of Mental Status score of 12, which indicated moderate cognitive impairment. The MDS documented the resident required extensive staff assistance with bed mobility, transfers, walk in room, limited staff assistance with walk in corridor, locomotion on and off unit, toilet use, and personal hygiene. R38 required supervision with eating. The MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility identified a census of 37 residents. The sample included 13 residents with two reviewed for activities of daily living (ADL's). Based on observation, record review, and interviews, the facility failed to provide consistent assistance and supervision with eating for Resident (R)14. This deficient practice placed the resident at risk for weight loss. Findings Included: - The electronic medical record (EMR) indicated the following diagnosis for R14: hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), cerebral infarction affecting right dominant side (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain ) osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), general anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), major depressive disorder (major mood disorder), hypertension (high blood pressure), and retention of urine (lack of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 38 residents. The sample included one resident reviewed for quality of care. Based on observation, record review, and interview, the facility failed to monitor Resident (R) 14's bowel movements and treat when indicated per physician orders which placed R14 at risk for digestive problems, impaired comfort, and bowel blockage. Findings included: -The Medical Diagnosis section within R14's Electronic Medical Records (EMR) included diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), cerebral infarction affecting right dominant side (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), general anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), major depressive disorder (major mood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 37 residents. The sample included 13 residents, with two residents reviewed for falls. Based on observation, record review, and interviews, the facility failed ensure fall interventions were implemented as care planned for Resident (R)16, which placed her at risk of major injury from falls Findings included: - R16's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure), history of falls, unsteady on feet, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of seven which indicated severely impaired cognition. The MDS documented that R16 required extensive assistance of one staff member for activities of daily living…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY - R10's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hypertension (elevated blood pressure), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), overactive bladder (a frequent and sudden urge to urinate that may be difficult to control), and stress incontinence (is the unintentional loss of urine). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R10 required extensive assistance of two staff members for activities of daily living (ADL's). The MDS documented R10 was not on a toileting plan. The MDS documented R10 received insulin (medication to regulate blood sugar), antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression), anticoagulant medication (class of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility identified a census of 37 residents. The sample included 13 residents with five residents reviewed for respiratory care. Based on observations, record reviews, and interviews, the facility failed ensure consistent respiratory care for Residents (R)13 and R32. This deficient practice placed the residents at risk for complications due to respiratory therapy. Findings Included: -The electronic medical record (EMR) indicated the following diagnosis for R13: colitis (inflammation of the large intestine, characterized by severe diarrhea and ulceration of the large intestine), urge incontinence (involuntary passage of urine occurring soon after a strong sense of urgency to void), chronic obstructive pulmonary disorder ( progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). R13's Quarterly Minimum Data Set (MDS) dated 03/22/22 noted a Brief Interview for Mental Status (BIMS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 37 residents. The sample included 13 residents with one reviewed for dialysis services (process of filtering and purifying blood using machines) . Based on observation, record review, and interviews, the facility failed to provide consistent care and services including communication between the facility and dialysis center for Resident (R)30. This deficient practice placed R30 at risk for complications related to dialysis services. Findings include: - The electronic medical record (EMR) indicated the following diagnosis for R30: chronic kidney disease, end stage renal disease (ERSD-- a terminal disease because of irreversible damage to the kidneys), atherosclerotic heart disease (hardening and narrowing of the blood vessels of the heart), type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), heart failure,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 37 residents. The sample included 13 residents, with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to monitor for Resident (R) 10's antihypertensive medication (class of medication used to treat hypertension [high blood pressure]) and failed to follow physician ordered parameters for monitoring of antihypertensive medication for R31 and R16. These deficient practices had the risk for side effects of unnecessary medications or complications. Findings included: - R10's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hypertension (elevated blood pressure), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), overactive bladder (a frequent and sudden urge to urinate that may be difficult to control), and stress incontinence (is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 37. The sample included 13 residents with five residents reviewed for unnecessary medications. Based on observations, interviews, and record reviews, the facility failed to implement behavioral monitoring associated with antidepressant medications (class of medications used to treat mood disorders and relieve symptoms of intense sadness, hopelessness and suicidal thoughts) and the facility failed to implement a discontinuation date (stop date) for as needed psychotropic ( medications which alter thoughts or mood) medication for Residents (R) 14, R31 and R33. This deficient practice placed the residents at risk for ineffective treatment and unnecessary side effects from psychotropic medications. Fingings lncluded: -The electronic medical records (EMR) indicated the following diagnoses for R14: hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), cerebral infarction affecting right dominant side (sudden death of brain cells due…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.